Rhinoplasty revision with dorsal augmentation by using PRF and temporalis fascia: case report

Background: Platelet rich fibrin (PRF) provides better healing, hemostasis, less pronounced edema and lesser resorption of the autologous augmentation material. The aim of this case report is to present a patient undergoing the 2nd revision rhinoplasty, after unsatisfactory results regarding function and esthetics. Case report: A middle-aged women, who had previously undergone rhinoplasties on two occasions in an external institution, presented with nasal dorsum irregularities, lower nasion, rocker deformity, bilateral internal and external valve insufficiency and acute nasolabial angle. The functional problem was solved by using bilateral spreader grafts and lateral crural strut grafts shaped by previously harvested septal cartilage. The reinforced lateral crura were separated from the hinge area and placed in the previously dissected alar rim pockets. The ptotic tip was reinforced by using an ANSA banner graft. The desired tip width, rotation and tip defining point position was achieved by domal creation sutures, interdomal sutures and tip position suture. Since the patient had an extremely thin skin, no tip refinement graft was used. Dorsal irregularities were to be addressed by using minor hump removal, fine drilling of residual irregularities with a diamond burr and camouflage on lay graft composed of previously harvested temporalis fascia with platelet rich fibrin matrix placed between the fascia and skin-soft tissue envelope. The patient has undergone regular follow ups since, reporting an improved function as well as a satisfactory esthetic result. Physical examination has shown normal nasal patency, uninterrupted brow tip line with smooth contours of the dorsum and normal nasolabial angle. Discussion: By reviewing the literature, most authors recommend PRF application as an addition to the diced cartilage camouflage graft for dorsal irregularities, showing superiority compared to the temporalis fascia, in terms of better healing, lesser edema, lesser resorption and smoother contours. In our case we decided to use temporalis fascia and PRF only, since the patient had an extremely thin skin, numerous minor irregularities and a lack of septal cartilage left for harvesting. It has provided a satisfactory result both subjectively and objectively upon follow up examinations by the surgeon

Rhinoplasty revision with dorsal augmentation by using PRF and temporalis fascia: case report

Background: Platelet rich fibrin (PRF) provides better healing, hemostasis, less pronounced edema and lesser resorption of the autologous augmentation material. The aim of this case report is to present a patient undergoing the 2nd revision rhinoplasty, after unsatisfactory results regarding function and esthetics. Case report: A middle-aged women, who had previously undergone rhinoplasties on two occasions in an external institution, presented with nasal dorsum irregularities, lower nasion, rocker deformity, bilateral internal and external valve insufficiency and acute nasolabial angle. The functional problem was solved by using bilateral spreader grafts and lateral crural strut grafts shaped by previously harvested septal cartilage. The reinforced lateral crura were separated from the hinge area and placed in the previously dissected alar rim pockets. The ptotic tip was reinforced by using an ANSA banner graft. The desired tip width, rotation and tip defining point position was achieved by domal creation sutures, interdomal sutures and tip position suture. Since the patient had an extremely thin skin, no tip refinement graft was used. Dorsal irregularities were to be addressed by using minor hump removal, fine drilling of residual irregularities with a diamond burr and camouflage on lay graft composed of previously harvested temporalis fascia with platelet rich fibrin matrix placed between the fascia and skin-soft tissue envelope. The patient has undergone regular follow ups since, reporting an improved function as well as a satisfactory esthetic result. Physical examination has shown normal nasal patency, uninterrupted brow tip line with smooth contours of the dorsum and normal nasolabial angle. Discussion: By reviewing the literature, most authors recommend PRF application as an addition to the diced cartilage camouflage graft for dorsal irregularities, showing superiority compared to the temporalis fascia, in terms of better healing, lesser edema, lesser resorption and smoother contours. In our case we decided to use temporalis fascia and PRF only, since the patient had an extremely thin skin, numerous minor irregularities and a lack of septal cartilage left for harvesting. It has provided a satisfactory result both subjectively and objectively upon follow up examinations by the surgeon

Use of fibula free flap in lower jaw reconstruction

Indikacije i prednosti primjene fibularnog režnja u rekonstrukciji donje čeljusti dobro su opisane u literaturi. Čvrsta kompaktna bikortikalna građa, duljina koštanog režnja, mogućnost multiplih osteotomija kosti, mogućnost simultanog rada dvaju kirurških timova te niska učestalost komplikacija i morbiditeta donorskog mjesta, značajke su koje fibularni režanj podižu na vrh rekonstrukcijske ljestvice za defekte donje čeljusti. Fibularni režanj vrlo je pogodan i za ugradnju dentalnih implantata, čime se postiže potpuna dentalna rehabilitacija. Ovaj rad je retrospektivna analiza desetogodišnjeg iskustva u rekonstrukcijama donje čeljusti fibularnim slobodnim režnjem. Prikazane su 44 mikrokirurške rekonstrukcije u onkoloških bolesnika kod kojih je resekcija primarnog malignog tumora usne šupljine uključivala i segmentalnu resekciju mandibule. Fibularni režanj se pokazao kao pouzdan te funkcijski i estetski izvrstan izbor u rekonstrukciji donje čeljusti. Unatoč brojnim prednostima fibularnog režnja, pri odabiru rekonstrukcijske metode u obzir se uzimaju i drugi parametri zdravstvenog stanja bolesnika, komorbiditet i navike. U starijih bolesnika s većim komorbiditetom mikrokirurška rekonstrukcijska metoda može predstavljati veći rizik za uspjeh liječenja. Značajan broj bolesnika s karcinomom usne šupljine su dugogodišnji pušači cigareta i konzumenti alkoholnih pića s izraženim aterosklerotskim bolestima što može biti važan razlog pri odabiru rekonstrukcijske metode. Individualiziran i multidisciplinaran pristup, adekvatno onkološko liječenje te optimalan odabir rekonstrukcijske i rehabilitacijske metode, u bolesnika liječenih od tumora usne šupljine, faktori su uspješnosti u kirurškom liječenju i kvaliteti života onkoloških bolesnika.Benefits and possibilities of applying fibular free flap in lower jaw reconstruction are well described in literature. The solid compact bicortical bone structure, the length of the bony segment, the possibility of multiple osteotomies, the possibility of two surgical teams approach and a low incidence of complications and morbidity of the donor site, are characteristics which raise fibular free flap to the top of the reconstructive ladder for mandibular defects. It is very suitable for dental implants placement, thus achieving complete oral rehabilitation. This report is a retrospective analysis of ten years of experience in reconstructions of the lower jaw with fibula free flap. There were 44 reconstructions in oncological patients following surgical treatment of the primary oral cancer, which involved segmental mandibular resection. Fibular flap has proven to be a reliable, functionally and aesthetically excellent method for lower jaw reconstruction. It is important to understand the reconstructive ladder and reconstruction varieties, while the best choice is not necessarily the most sophisticated method. In older, severe oncological patients with numerous comorbidities, microsurgical reconstruction may sometimes bring too much risk for a patient. This is very important to emphasize, especially in lower jaw reconstructive surgery, where oncological patients are in many cases smokers and alcohol consumers with atherosclerotic illnesses. In patients treated with head and neck tumors, the crucial factors for good results and patient satisfaction are individualized and multidisciplinary approaches, proper oncological treatment and deliberate choice of reconstruction and rehabilitation methods

Rinogeni meningitis uzrokovan kongenitalnim kolesteatomom apeksa piramide: simultano kirurško liječenje transotičkim i transsfenoidnim pristupom

A 66-year-old male patient was admitted due to high fever, severe headaches and disturbance of consciousness. Meningitis was confirmed by lumbar puncture and intravenous antimicrobial therapy was started. Since he had undergone radical tympanomastoidectomy 15 years before, otogenic meningitis was suspected, so the patient was referred to our department. Clinically, the patient manifested watery discharge from the right nostril. Microbiological analysis verified Staphylococcus aureus in a cerebrospinal fluid (CSF) sample acquired by lumbar puncture. Radiological work-up, including computed tomography and magnetic resonance imaging scans, showed an expanding lesion of the petrous apex of the right temporal bone disrupting the posterior bony wall of the right sphenoid sinus with radiological characteristics indicating cholesteatoma. Those findings confirmed rhinogenic meningitis caused by expansion of the petrous apex congenital cholesteatoma into the sphenoid sinus, allowing nasal bacteria to enter the cranial cavity. The cholesteatoma was removed completely by the simultaneous transotic and transsphenoidal approach. Since the right labyrinth was already non-functional, there was no surgical morbidity after labyrinthectomy. The facial nerve remained preserved and intact. The transsphenoidal approach enabled removal of the sphenoid portion of the cholesteatoma and two surgeons met together at the level of the retrocarotid segment of the cholesteatoma, completely removing the lesion. This case represents an extremely rare condition in which a petrous apex congenital cholesteatoma expanded through the petrous apex to the sphenoid sinus, causing CSF rhinorrhea and rhinogenic meningitis. According to available literature, this is the first case of petrous apex congenital cholesteatoma causing rhinogenic meningitis successfully treated with the simultaneous transotic and transsphenoidal approach.Bolesnik u dobi od 66 godina primljen je zbog visoke temperature, jake glavobolje i poremećaja svijesti. Lumbalna punkcija potvrdila je meningitis i započeta je intravenska antibiotska terapija. Budući da je 15 godina ranije kod bolesnika rađena radikalna timpanomastoidektomija, postavljena je sumnja na otogeni meningitis te je upućen na našu Kliniku. Nakon primitka je uočena desnostrana rinolikvoreja, a ponovljenom lumbalnom punkcijom u likvoru je izoliran Staphylococcus aureus. Radiološka obrada uključujući kompjutoriziranu tomografiju i magnetsku rezonancu pokazala je ekspanzivnu leziju vrha piramide desne temporalne kosti s destrukcijom stražnje stijenke sfenoidnog sinusa i radiomorfološkim osobinama kolesteatoma. Ovi nalazi potvrdili su da se radi o rinogenom meningitisu koji je uzrokovan širenjem kongenitalnog kolesteatoma vrha piramide u sfenoidni sinus, što je omogućilo prodor bakterija iz nosa u endokranij. Kolesteatom je u cijelosti odstranjen simultanim kombiniranim transotičkim i transsfenoidnim pristupom. Budući da je desni labirint od ranije bio nefunkcionalan, nije bilo kirurškog morbiditeta nakon labirintektomije. Očuvani su integritet i funkcija ličnog živca. Transsfenoidni pristup omogućio je odstranjenje sfenoidnog dijela kolesteatoma, a oba operatera susrela su se na razini retrokarotidnog segmenta kolesteatoma koji je tako odstranjen u cijelosti. Ovaj bolesnik predstavlja iznimno rijedak slučaj kod kojega se kongenitalni kolesteatom vrha piramide proširio u sfenoidni sinus uzrokujući rinolikvoreju i rinogeni meningitis. Prema dostupnoj literaturi, ovo je prvi takav slučaj koji je ujedno uspješno liječen simultanim transotičkim i transsfenoidnim pristupom

Accidental removal of glottic carcinoma during direct laryngomicroscopy and follow-up bronchoscopy: a case report

Introduction: Endoscopic surgery for glottic carcinoma is a standardized and safe procedure. However, in certain circumstances and localizations of the lesion, airway management prior and during surgery may pose a significant challenge. Accidental removal of glottic carcinoma during intubation is a very rare occurrence and poses an interesting diagnostic and therapeutic problem. Case report A patient with suspect T1a glottic laryngeal carcinoma was referred to our department because of hoarseness that had been going on for the past month. She had no other complaints. The patient was healthy, a non-smoker and had no other risk factors. The examination revealed a well-perfused lesion in the front two thirds of the left vocal cord. Direct laryngomicroscopy under general anesthesia was indicated. During intubation, the lesion was accidentally torn off with the Storz endoscope. During direct laryngoscopy, no lesion was observed, a limited excision of the tumor base was performed. The tissue was sent for urgent PH analysis and mild atypia was observed by the pathologist. Subsequently, bronchoscopy was performed and the aspirate was sent for PH analysis, which revealed that the aspirate contained carcinoma in situ. The patient was followed-up regularly. During the first 6 months postoperatively, the patient was monitored on a monthly basis. Her voice was fine, and she had no other complaints. One year after the surgery, the patient has been checked-up every 2 months and is still without any complaints. Conclusion: In general, direct laryngomicroscopy is a safe operative method with a high success rate. However, considering the localization and the fact that it is performed under general anesthesia, various problems can occur. This case shows that, despite the difficulties that may occur during the surgery, a correct decision at a moment may lead to the desired result. In addition to the patient\u27s survival, which is the most important aim, the quality of life can also be preserved with the right therapeutic method. This was the case with our patient, who has not had any complaints so far, nor has she shown any signs of recurrence of the disease

Accidental removal of glottic carcinoma during direct laryngomicroscopy and follow-up bronchoscopy: a case report

Introduction: Endoscopic surgery for glottic carcinoma is a standardized and safe procedure. However, in certain circumstances and localizations of the lesion, airway management prior and during surgery may pose a significant challenge. Accidental removal of glottic carcinoma during intubation is a very rare occurrence and poses an interesting diagnostic and therapeutic problem. Case report A patient with suspect T1a glottic laryngeal carcinoma was referred to our department because of hoarseness that had been going on for the past month. She had no other complaints. The patient was healthy, a non-smoker and had no other risk factors. The examination revealed a well-perfused lesion in the front two thirds of the left vocal cord. Direct laryngomicroscopy under general anesthesia was indicated. During intubation, the lesion was accidentally torn off with the Storz endoscope. During direct laryngoscopy, no lesion was observed, a limited excision of the tumor base was performed. The tissue was sent for urgent PH analysis and mild atypia was observed by the pathologist. Subsequently, bronchoscopy was performed and the aspirate was sent for PH analysis, which revealed that the aspirate contained carcinoma in situ. The patient was followed-up regularly. During the first 6 months postoperatively, the patient was monitored on a monthly basis. Her voice was fine, and she had no other complaints. One year after the surgery, the patient has been checked-up every 2 months and is still without any complaints. Conclusion: In general, direct laryngomicroscopy is a safe operative method with a high success rate. However, considering the localization and the fact that it is performed under general anesthesia, various problems can occur. This case shows that, despite the difficulties that may occur during the surgery, a correct decision at a moment may lead to the desired result. In addition to the patient\u27s survival, which is the most important aim, the quality of life can also be preserved with the right therapeutic method. This was the case with our patient, who has not had any complaints so far, nor has she shown any signs of recurrence of the disease